Palliative Care Flashcards
Pain ladder
- simple analgesia
- weak opioid
- strong opiates
Simple analgesia
Paracetamol
NSAIDS
Aspirin
Weak opiates
Codeine
Tramadol
Dihydrocodeine
Strong opiates
Morphine
Fentanyl patches
Diamorphine
Oxycodone
Bowel obstruction + advanced malignancy
Treatment
Palliative colostomy
*NGt initial step for decompression esp if vomiting fecal matter
End stage lung ca + worsening cough +SOB + pleuritic chest pain
Pleural effusion CXR
Treatment>
Pleural aspiration - single best management
If extremely ill - not fit for X-ray - consider morphine for SOB
Outpatient on oral morphine - develops side effects
Switch to oral oxycodone
Oxycodone - double potency of morphine w/ fewer side effects
Antiemetic for increased intracranial pressure
Cyclizine
Medication to help shrink oedema and decrease raised ICP
Dexamethasone
Treatment of hypercalcemia secondary to bone mets
- IV fluids
+
IV Bisphosphonates
Features of hypercalcemia Neuro GIT Renal CVS
Bones stones moans groans
N- lethargy confusion depression
G- constipation nausea vomiting
R - polyuria, polydipsia
C- short QT
Severe bleeding in palliative patient
Management?
Midazolam + morphine = subcutaneous
Management of pain due to bone mets
1st & 2nd line
1st line- radiotherapy
If fails -
Bisphosphonate + NSAIDS (2nd line)
Management of acute pain due to mets after radiotherapy
Morphine sulphate
Management of neuropathic pain
Gabapentin
Amitriptyline
Pregabalin
Duloxetine
Management of trigeminal neuralgia
Carbamazepine (anticonvulsant)
Gold standard investigation for bone mets
- MRI*
2. Bone scintigraphy
Sites commonly affected by bone mets
Most common origins
SPRSL
Spine >pelvis > rib>skull> long bones
Origins -
Males - prostate, lung
Females - breast,lung
Main dose calculation - oral morphine
Sum of all amounts of morphine being received in 24 hrs
__________________________________________________
2
So it can be given 2x a day as a main dose
Oral morphine breakthrough dose calculation
Breakthrough dose = additional dose
= 1/6 of total daily dose given PRN 4 hrly
= total main dose / 6
Or
10% of total dose given PRN 4hrly
Terminal patient ask for meds to end life
What do you do?
Refer to hospice care
What is written in 1a of death certificate?
Disease or condition directly leading to death - clear + specific
What painkiller should not be given in elderly palliative patients
Oral codeine - barely tolerable
**note there is no such thing as SC codeine
It is always oral
Side effects of oral codeine develop, what can it be replaced with
Buprenorphine patch - optimal
Pick unless the pt is currently in pain as it takes time to work
Or
SC morphine
Treatment of capsular pain
NSAIDS - ibuprofen, naproxen
Anticipatory meds (only given subcutaneously) a-For pain and breathlessness b-nausea and vomiting c-anxiety d-noisy resp secretions
A- morphine sc
B- haloperidol sc
C- midazolam sc
D- hyoscine butylbromide sc
Treatment of intractable hiccup due to liver ca
Metoclopramide
Others - domperidone , nifedipine
What causes the hiccup in liver mets
Diaphragmatic irritation = phrenic n irritated = hiccup
Treatment of central hiccups
Chlorpromazine
Anti emetic in renal failure/hypercalcemia/drug induced vomiting
1.Haloperidol
Except in Parkinson’s give
2.levomepromazine (second line)
Antiemetic in raised ICP
Cyclizine
Antiemetic in delayed gastric emptying
Metoclopramide
Antiemetic in chemo/radio
Ondansetron
Antiemetic for hyperemesis
1st line - ZINEs cyclizine, promethazine
2 - IV metoclopramide, ondansetron
3- steroids
Antiemetic in Ménière’s disease/ BPPV/ Vestibular neuritis
Buccal prochlorperazine
How should the prescription of controlled drugs be written
Quantity - Figures + words **
Signature - must be handwritten
Age and date of birth of patient - better written, not legally required unless <12yrs
** except oral morphine
Step up medication from NSAIDS for gastric ulcers
Tramadol - safe to use
Noisy respiratory secretion sin late cancer patient
antimuscarinics
Sc hyoscine
Others : glycobyrronium bromide sc
What delivery method of medication preferred in palliative care
Subcutaneous over IV
Morphine vs oxycodone
Oxycodone is double the potency and has fewer side effects
Morphine in treatment of cough
Inhibits cough reflex
Most appropriate management in pt with cerebral mets - headache + intractable vomiting?
High dose dexa - initial treatment to shrink mass and oedema
If GCS = 8 - mannitol (rapid action)
Very low GCS + neuro deficit = urgent craniotomy
Conversion of oral dose of morphine to subcutaneous
Divide dose by 2
Conversion of oral dose of morphine to subcutaneous diamorphine
Divide by 3
Conversion of oral dose of tramadol to IV morphine
Divide dose by 20
Management of catastrophic bleeding in palliative care
10mg SC midazolam for anxiety
10mg SC morphine sulphate for pain if required
SOB in palliative patients treatment
Oral morphine
Palliative patients with bowel obstruction
Medication ?
Definitive tx?
Initial tx?
SC hyoscine butylbromide
Def -palliative stoma
Initial - NGT
Legal prescription requirements (4)
Patient Name + address
Age + DOB - if <12
Date
Prescriber address
If handwritten - FP10 form
Handwritten signature
Cavitary lesion in pt with lung ca
+ low grade fever
Treatment
Antibiotics
PEG vs NGT feed in palliative care
Short term - NGT
Long term - PEG
Manage to go leak of PEG after insertion in palliative care
Reassure and continue feed
One off leaks may occur as long as there is no infection
